Intravenous Catheter Employed in Peritrochlear Injection of Triamcinolone in the Treatment of Trochleitis

Abstract

Purpose:

Injection of corticosteroid into the peritrochlear region is a widely practiced and highly successful treatment option for trochleitis, conventionally employing a 25- or 27-gauge needle for the steroid injection. Injection into the vascular-rich peritrochlear region poses a risk, albeit rare, of central retinal artery occlusion or orbital hemorrhage. We describe a potentially safer method of delivering triamcinolone to the peritrochlear region using a 24-gauge intravenous catheter.

Methods:

Interventional retrospective case series including all patients who received peritrochlear injections of triamcinolone via intravenous catheter for trochleitis by a single surgeon (BJW). Surgical technique: After a subcutaneous wheel of local anesthetic was delivered to the medial upper eyelid skin nearest to the trochlea, a 24-gauge intravenous catheter was used to penetrate the skin and orbital septum. Once past the septum, the needle was removed and the blunt catheter was advanced into the peritrochlear region. A 1-cc syringe filled with triamcinolone 40mg/ml was attached to the catheter. After pulling back to ensure that the catheter was not intravascular, triamcinolone was delivered to the orbit. The catheter was then removed.

Results:

Ten catheter injections were performed on 3 patients over an eight-year period. There were no complications.

Conclusion:

Injection of corticosteroid into the peritrochlear region using the commonly available 24-gauge intravenous catheter is an effective and theoretically safer alternative to typical injection using a 25-gauge needle for treatment of trochleitis. Use of non-particulate steroid solutions may further decrease the risk of adverse events.

Précis:

Injection of corticosteroid into the peritrochlear region using the commonly available 24-gauge intravenous catheter is an effective and theoretically safer alternative to typical injection using a 25-gauge needle for the treatment of trochleitis.

Introduction

Trochleitis is a local inflammation of the trochlea, a ring-like cartilaginous structure containing the superior oblique tendon and a surrounding fibrovascular sheath innervated by local sensory nerves.¹ It is characterized by new onset, constant, unilateral pain, particularly in the superomedial orbit, aggravated by eye movement or palpation of the trochlear region.^1,2 Though the etiology of trochleitis is often idiopathic, it may be secondary to inflammatory diseases (including rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, psoriasis, sinusitis, enteropathic arthropathy), trauma, and tumor.^1,3 Trochleitis may coexist with ipsilateral migraine and successful treatment of the trochleitis usually improves the concurrent headaches. However, migraine treatment alone typically does not alter the course of the trochleitis.⁴

Currently, no evidence-based treatment guidelines exist for the management of trochleitis. Present treatment paradigms entail oral anti-inflammatory medications, including non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, as well as steroid injection into the peritrochlear region. Injection of corticosteroids (betamethasone, dexamethasone, triamcinolone, and methylprednisolone) into the peritrochlear region, while not an FDA-approved use of these medications, is a widely practiced and highly successful treatment option for trochleitis.^3–8 These have been found to provide complete relief in 40–95% of patients by 48 hours, lasting weeks to years.^3–8 Recurrences often respond to subsequent injections.

Conventionally, a 25- or 27-gauge needle is employed. However, injection of steroid suspensions into the peritrochlear region may be complicated by central retinal artery occlusion (CRAO), globe perforation, orbital hemorrhage, fat atrophy, or depigmentation.⁹ The embolic risk with peritrochlear injections of steroid lies within the particulate nature of steroid suspensions,¹⁰ which can travel retrograde through the peritrochlear vessels (supratrochlear artery, supraorbital artery, dorsal nasal artery) to become emboli in the choriocapillaris, ciliary branches, or central retinal artery. Corticosteroid injection-induced CRAO has been described in the treatment of chalazion, periocular capillary hemangioma, and thyroid eye disease.^11–14

Given the potential risk of visual loss associated with intraorbital steroid injections, a safer technique of steroid injection for trochleitis would be beneficial. In order to avoid unintended intravascular injection and reduce the risk of orbital hematoma, herein we describe a novel technique of peritrochlear steroid injection using the commonly available intravenous catheter, instead of the typical 25- or 27-gauge needle, to perform the steroid injection, ensuring safer drug delivery to the intended region.

Methods

A retrospective case series of patients with trochleitis who underwent peritrochlear injection of 40mg/ml triamcinolone from September 2009 to July 2017 using the described technique. The study was approved by the Internal Review Board of Columbia University, adhered to the tenets of the Declaration of Helsinki, and was conducted in full compliance with the regulations of Health Insurance Portability and Accountability Act (HIPAA) of 1996. Consent was obtained and is on file from the patient to display full face images documenting this procedure.

Surgical technique

After a subcutaneous wheal of local anesthetic was delivered to the medial upper eyelid skin nearest to the trochlea, a 24-gauge intravenous catheter was used to penetrate the skin and orbital septum. Once past the septum, the needle was removed and the blunt catheter was advanced into the peritrochlear region. A 1-cc syringe filled with triamcinolone 40 mg/ml was attached to the catheter. After pulling back to ensure that the catheter was not intravascular, triamcinolone was delivered to the orbit. The catheter was then removed. See Surgical Video.

Results

Three patients, all females, diagnosed with unilateral trochleitis were included in this case series. All patients were treated with 0.3 to 0.5 cc of triamcinolone 40mg/ml delivered to the peritrochlear region using the described technique. Patient 1 with trochleitis and migraine reported relief of symptoms for 11–12 weeks on average and received 6 injections over a six-year period for recurrences. Patient 2 had complete remission after 3 injections, each approximately 2.5 months apart. Patient 3 did not have relief after a single injection and was lost to follow up. No complications were observed. Other clinical data is summarized in Table 1.

Table 1.

Patient demographics.

Patient	Age	Sex	Laterality	Number of injections	Volume of 40mg/ml triamcinolone injected (cc)	Response duration (weeks)	Mean duration between injections (days)	Time between injections (days)	Follow up	Complications	Concurrent pain relief medications
1	48	F	Right	6	0.3	11–12	377	105–1127	6 years	None	Valproic acid, amitriptyline, bupropion
2	82	F	Right	3	0.3–0.4	9–10	67	63–70	4 months	None	Ibuprofen (only prior to 1st injection)
3	34	F	Left	1	0.5	None	__	__	2 weeks	None	Diazepam, hydrocodone/acetaminophen, olanzapine, tramadol

F=female; M=male.

Discussion

Local injection of steroid is frequently employed in orbital inflammatory processes including trochleitis, chronic orbital inflammation, and thyroid eye disease. Injections are typically performed with a 25- or 27-gauge needle.^1,9,15 Leibovitch et al. found that intraorbital injections of triamcinolone substantially improved cases of idiopathic orbital inflammation up to 10 months after injection.¹⁵ Additional studies suggest that intraorbital corticosteroid injections are effective in managing patients with refractory orbital inflammation after oral steroids and reduce the rates of recurrent disease.^16–17 Periocular injection of triamcinolone has also been employed to reduce diplopia and extraocular muscle size in new onset thyroid eye disease.¹⁸ In general, local steroid injections have the advantage of providing concentrated anti-inflammatory effect without the morbidity associated with systemic corticosteroids. However, complications of orbital injections may include central retinal artery occlusion (CRAO) and orbital hemorrhage, each potentially leading to permanent vision loss.^9,15

CRAO is a rare complication that has been demonstrated in particulate corticosteroid suspension injections performed on several facial regions, including the forehead, eyelid, orbit, nose, maxilla, mandible, and ears.^{12, 19–27} In documented cases of CRAO following injection, the vessels occluded are primarily the choriocapillaris, posterior ciliary artery branches, and central retinal artery, which have mean vessel lumen diameters of 20–40 μm, 500–700 μm, and 123–144 μm, respectively.^28–30 Corticosteroid preparations have varying particle sizes with a maximum particle size of >500 μm, exceeding the lumen diameter of the commonly occluded vessels and their smaller branches. In addition, triamcinolone has been observed to form larger and more densely packed aggregates compared to betamethasone acetate and methylprednisolone, with the largest particles more than 12 times the size of red blood cells.^31–32 Particles larger than vessel lumen diameter causing vascular occlusion has been demonstrated in animal models.^33–34 The commonly accepted mechanism for vascular occlusion in periocular steroid injection is that the pressure from intra-arterial injection into branches of the ophthalmic artery (e.g. supraorbital artery) results in retro-orbital flow of corticosteroid particles followed by a subsequent antegrade arterial flow that drives the corticosteroid particles to occlude the smaller lumen vessels of the choriocapillaris, ciliary branches, and central retinal artery.³⁵ Dexamethasone and betamethasone sodium phosphate exist in pure solution, theoretically eliminating the risk of artery occlusion.

Of the larger case series published describing peritrochlear steroid injections, the complication rate ranged from 0 to 16.7%.^3,4,6,7 In a review of peritrochlear injections, peritrochlear hemorrhage was encountered in 1.6%.³⁶ There were no reported episodes of vision loss, diplopia, or retinal artery occlusion.

Triamcinolone (10–40 mg), betamethasone sodic phosphate (3mg), betamethasone acetate (3mg), dexamethasone (1–4mg), and methylprednisolone (1–3mg) have been employed to treat trochleitis, alone or in combination, typically delivered in total volumes of 1 cc.^2–7 Smith and colleagues provide the largest series with 25 patients undergoing peritrochlear injection.³ On average, patients received 4 serial injections (range 1–18) of dexamethasone (1–4mg), with or without triamcinolone (20–40 mg) mixed with lidocaine. Twenty-four percent achieved remission after a single injection, 56% experienced recurrences, and 20% had no improvement. Of those with recurrences, the duration of pain control after injection ranged from 12 hours to 12 months, with the majority improving for 4 weeks to 4 months. The response to treatment in our series was consistent with Smith’s cohort, although we used only triamcinolone and typically smaller doses.

There are a limited number of series describing use of only particulate or only non-particulate steroid preparations for trochlear injection and no series directly comparing the two. Jarrín reported 8 patients receiving triamcinolone injection for trochleitis.⁷ Of these, 62% had improvement (1 with complete remission, 4 with partial improvement, and 3 without improvement) after a single injection. Two of the 3 failures had two subsequent injections without improvement. Triamcinolone dosages were not reported. Giannaccare described 13 patients who underwent trochlear injection with 1 cc of 40mg/cc triamcinolone for acquired Brown syndrome secondary to trochleitis.⁸ After a median of 1.3 injections, 84.6% had complete remission. In contrast, Chanlalit’s series includes 14 patients with trochleitis, many unresponsive to oral medications, who received 1–3 mg of dexamethasone with lidocaine injections.⁶ Eighty-six percent had complete remission, 14% had partial response, and there were no treatment failures. In Smith’s series, there was no obvious correlation with duration of response and addition of triamcinolone over dexamethasone alone.³

Proponents of particulate corticosteroid suspensions have cited theoretical longer duration of action. While there have been no prospective trials comparing particulate versus non-particulate steroid injection for trochleitis, a meta-analysis focusing on the efficacy of particulate versus non-particulate corticosteroids in epidural injections found no statistically significant difference in terms of pain reduction or improved clinical outcomes.³⁷ In light of several reported devastating neurovascular events surrounding the use of particulate steroids in epidural injections, the authors make the strong recommendation that nonparticulate steroids should be considered first line agents when performing epidural steroid injections.³⁷

In our series, we performed local delivery of steroid to the orbit utilizing a technique with theoretically decreased risk of inadvertent intravascular injection. Using a standard intravenous catheter, the guide needle and overlying catheter are inserted percutaneously into the orbital fat just posterior to the orbital septum. The guide needle is removed, leaving only the blunt plastic cannula in the orbit. This cannula can then be further advanced to the desired, “high risk” area adjacent to the trochlea without the fear of inadvertent intravascular insertion or puncture.

A similar technique has been described for sub-tenon injection in the treatment of uveitis. In these sub-tenon injections, an intravenous catheter was employed to allow safer drug delivery into the posterior sub-tenon space, theoretically preventing inadvertent globe perforation.³⁸ A catheter based approach has also demonstrated a decreased risk of vascular uptake during epidural injections.³⁹ In addition, the use of blunt cannulas to deliver dermal filler has been proposed as a method to avoid intravascular injection.⁴⁰ Despite their common usage, utilizing intravenous catheters in extra-venous settings is off-label.

We did not encounter any adverse events. However, orbital hemorrhage and CRAO are so rare that a meaningful comparison between our technique and injections using needles would require a prospective, randomized study of grand proportions. Drawbacks of this technique compared to the typical orbital injection include the additional cost of the cannula and the additional time required to insert the cannula. Despite these limitations, we suggest that the intravenous catheter may be a safer alternative to the 25-gauge needle for peritrochlear and intraorbital injection, especially if particulate corticosteroid suspensions are used. Given a lack of evidence for the superiority of particulate corticosteroid suspensions for peritrochlear injection, practitioners should consider non-particulate steroid solutions as first line agents to further reduce the risk of sight-threatening embolic events.